Background context: Cauda equina following a prosthetic Disc nucleus replacement has never been reported. Purpose: To describe a case of Cauda equina following migration of the Prosthetic disc nucleus and possible cause. Study design: Case report and review of literature. Patient Sample: Case report. Outcome measures: 2 patients. Report of presenting symptoms and review of radiographs. Method/description: A 24-year-old man presented with progressively worsening pain radiating down his right leg and low back pain. His MRI scan showed a disc bulge at L4/5 for which we underwent decompression and discetomy. 4 months later he presented again with same symptoms. MRI imaging showed a disc prolapse at L4/5. He underwent a revision decompression discectomy and a prosthetic disc nucleus replacement. On the 4th postoperative day he complained of urinary retention and was unable to move his right ankle with loss of sphincter tone. The plain radiographs showed that the prosthetic disc nucleus had migrated posteriorly. He was immediately taken to theatre, which showed posterior migration of the prosthetic disc nucleus compressing the theca and displacing the nerve root. The prosthetic disc nucleus was removed from the space relieving the tension of the nerve root and the theca. Conclusions: Migration of Prosthetic disc nucleus can lead to cauda equina and this needs to be explained to the patient as possible risk factor. The angle of the vertebrae has to be measured before selecting a patient. If angle below 5 degree it is a high risk patient

Introduction: Traumatic cauda equina constitutes a significant number of presentations of spinal cord injury in the emergency setting. Cauda equina syndrome from lumbar disc herniation accounts for up to 2–3% of all disc herniation. The aim of this study was to investigate and compare the success of surgical intervention between cauda equina that results from acute versus chronic pathology. Patients and Methods: 47 patients who underwent surgery for cauda equina syndrome due to acute trauma or a herniated disc in the period between 2000 and 2006. All presented with one or more of the categorical symptoms associated with cauda equina (CE) syndrome such as sciatica, saddle hypoaesthesia, urinary incontinence and others. All patients had been catheterised at the time of admission to the National Spinal Unit. Patients presenting with acute CE underwent surgery within 24 hours. Patients presenting with chronic pathology underwent surgery within 48 hours. Differences in postoperative resolution of neurological function is compared between the two groups. The role of preoperative duration of symptoms in recovery of bladder function was examined. Results: The follow-up ranged from 12–86 months. In 33 patients (70%) excellent results were achieved, in 8 patients (18%) good results were achieved and in 6 patients (10%) poor results were achieved. There was no statistically significant difference concerning the time between the onset of symptoms and surgical decompression. Significant difference appears to exist between the neurological recovery of those patients who underwent surgery subsequent to acute trauma in comparison to those with longer standing pathology. Conclusion: Surgical intervention results in the resolution of neurological symptoms in those patients who present with symptoms consistent with cauda equina. This result is more apparent in those who presented with acute trauma

Purpose: Cauda Equina Syndrome (CES) is a frequently cited red flag in patients presenting with back pain and is considered a surgical emergency. The purpose of this paper is to review the current literature on CES, to establish consensus on its definition, clinical presentation and possible aetiology. Methods: The databases (Medline 1951 →, Embase 1974 →, Cinhal 1982 →) were searched using the key words Cauda Equina Syndrome and:. Definition,. Clinical presentation. Signs and Symptoms. Pathology. Aetiology. The findings from these searches were coded to identify individual aspects of CES. The consistency of each aspect was then classified using The Guidelines Development Groups format (where 100% coverage = ‘unanimity’; 75–99% = ‘consensus’; 51–74% = ‘majority view’; and 0– 50% = ‘no consensus’), and the findings summarized. Results: The electronic searches revealed 104 papers comprising case reports, case studies, literature reviews, expert opinion and papers based on clinical experience. From these, there were widely varying descriptions of the definition, clinical presentation and aetiology of CES, and no individual aspects reached 100% agreement. The individual aspect with greatest agreement was found to be bladder dysfunction. Conclusion: Cauda Equina Syndrome is considered a discrete clinical entity; however there is inconsistency within the literature as to its definition, clinical presentation and aetiology. To document its prevalence, clarity in definition is needed. Identifying this surgical emergency is paramount for all those who undertake spinal assessments

To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms. NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows. Orthopaedic. 60. Accident and Emergency. 32. Other. 25. The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory

Background. The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined. Aim. Purpose of this study was to examine the presentation, timing of surgery, peri-operative complications and outcome of Cauda Equina Syndrome in relation to Body Mass Index. Methods. A single centre retrospective analysis was performed on 40 patients admitted with cauda equina syndrome. Data was collected regarding patient demographics, body mass index (BMI), co-morbidities, onset & mode of presentation and speed of functional recovery following surgery. Results. There were 18 males and 22 females with an overall average age of 38.9 years. The average height was 168.7 cm, and the average weight was 89.3 kg, giving an average BMI of 30.6 Kg/m2. 80% of patients were considered overweight (BMI 25–29.5) or obese (BMI >30). The average duration of back or leg pain prior to presentation was 4.2 years for the obese group and 1.3 years for the non-obese group. Bilateral sciatica, urinary incontinence and dense peri-anal numbness were the predominant presenting features in the obese group. Onset of symptoms was slow and gradually evolving in the obese group compared to the fast onset in the obese group. In the non-obese group, 71% underwent surgery within 24 hrs as opposed to 31% in the obese group. Average follow-up was 6months (6 weeks to 14 months). We observed that higher the BMI more slower the recovery with residual neurology and sphincter dysfunction. Patients in ideal group had prompt early symptomatic recovery with no residual neurology and full bladder recovery. There was correlation between increasing BMI and increased rate of surgical complications. Conclusion. This is the first study exploring the impact of body mass index on CES presentation and outcome. Specific care in establishing an early diagnosis in obese individuals is imperative for timely intervention

Background. The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined. Aim. The purpose of this study was to determine the effect of body habitus on the presentation and outcome of cauda equina syndrome. Study Design. Single-centre case series. Methods. A retrospective analysis was performed on 40 patients admitted with cauda equina syndrome. Data was collected regarding patient demographics, body mass index (BMI), co-morbidities, onset & mode of presentation and speed of functional recovery following surgery. Results. There were 18 males and 22 females with an overall average age of 38.9 years. The average height was 167 cm, and the average weight was 95.3 kg, giving an average BMI of 30.3 Kg/m2. 80% of patients were considered overweight (BMI 25-29.5) or obese (BMI >30). The average duration of back or leg pain prior to presentation was 4.2 years for the obese group and 1.3 years for the non-obese group. Bilateral sciatica, urinary incontinence and dense peri-anal numbness were the predominant presenting features in the obese group. Onset of symptoms was fast and rapidly evolving in the non-obese group compared to the obese group. In the non-obese group, 71% underwent surgery within 24 hrs as opposed to 31% in the obese group. There was correlation between increasing BMI and increased rate of surgical complications. Recovery of motor and sensory function appeared to occur more quickly in the non-obese compared to the obese group. Recovery of bladder continence was 83% in non-obese patients and 69% in the obese group at 6 months. Conclusion. This is the first study exploring the impact of body mass index on CES presentation and outcome. Specific care in establishing an early diagnosis in obese individuals is imperative for timely intervention

The purpose was to present a case of cauda equina entrapment in a lumbar burst fracture with associated lamina fracture and to review the literature and assess the appropriateness of current practices for cauda equina decompression. Reported incidence of cauda equina entrapment in the lamina fracture of lumbar burst fractures is 13–17%. Anterior surgery alone for decompressing the cauda equina in patients with lumbar burst fractures and associated lamina fractures will not always address the problem. We therefore suggest that posterior exploration may be the preferred approach if the aim of surgery is to decompress the neural elements

Purpose. To establish if the subjective features of both bilateral leg pain and sexual dysfunction are presenting features in cauda equina syndrome (CES). Background. There appears to be conflicting expert opinion ‘red flag’ symptoms in the context of CES with many experts basing clinical decisions on the objective clinical findings only. Bilateral radiculopathy has been suggested as a possible sign of suspected CES, although a consensus statement by BASS and SBNS makes no reference to either this or sexual dysfunction. However, bilateral leg pain is included in the NICE clinical knowledge summary and sexual dysfunction is highlighted within CES guidance by the American Association of Neurological Surgeons. Methods. The clinical documentation of patients undergoing urgent magnetic resonance imaging (MR) due to clinical suspicion of cauda equina syndrome (CES) was reviewed over 12 months. Patients questioned regarding sexual function were included in this retrospective analysis (n=179), along with those with bilateral leg pain (n=294). Patients with confirmed cauda equina compression (CES +ve) were compared to those without (CES -ve). A logistic regression was applied to find the odds ratio. Results. In CES +ve 37.5% had sexual dysfunction, 48% had bilateral leg pain. CES –ve 14% had sexual dysfunction, 27% bilateral leg pain. Both significant to p=0.015 with an odds ratio of 3.6 and 2.5 respectively. Conclusions. Both sexual dysfunction and bilateral leg pain do appear to be ‘red flags’ for CES and should therefore be asked in the ED to aid clinical reasoning when suspecting this diagnosis. No conflicts of interest. No funding obtained

Introduction. Cauda Equina is a condition requiring urgent operative intervention to avoid debilitating long term neurological compromise. The recommended maximium time delay before lack of surgical decompression results in persisting neurological deficit has been suggested to be 24 hrs and more recent studies have even indicated 48 hours as acceptable. We wanted to assess if any persisting neurological deficit occurred in our practice when treated at 12 hours or less. Aim. To assess if patients treated within half of the maximum recommended time for surgical decompression following cauda equina i.e 12 hours, are still pre-disposed to persisting neurological compromise. Methods. We reviewed all patients who underwent a spinal decompression for cauda equina, based on clinical presentation, examination and magnetic resonance imaging at our institution. Over a seven year period, seven patients were found to have operative findings consistent with cauda equina syndrome. The clinical presentation, time from presentation to operative decompression and type of procedure done, as well as the clinical review at follow up, were noted. Results. The time from presentation to operation was 8 hours 30 mins to 11 hours 48 in 6 patients and 25 hrs in one patient. All seven patients had resolution of symptoms except for dermatomal sensory deficit. Two patients had some recurrence of sciatica, two of these patients having similar operations done at the same level within 18 months. Discussion. Our study shows that urinary compromise resolves with early decompression but that persisting neurological symptoms in the form of sensory deficit can persist even when decompression is performed within 12 hours. We conclude that early decompression is necessary but it does not alleviate all neurological symptoms

Background. Cauda equina syndrome (CES) is a physical process. There is compression of the cauda equina resulting in arrest of the electrochemical signal from the central nervous system. Previous studies have demonstrated that anthropomorphic features influence nerve conduction properties. Aim. We therefore sought to if there was an association between biophysical parameters and CES. Setting and design. Single centre retrospective comparative study. Method and materials. We analysed consecutive patients who had elective lumbar discectomy. Demographic data-including age, gender, height, weight and BMI were recorded. Identical information was collected in consecutive patients who underwent emergency lumbar discectomy for MRI-proven CES. Results. There were 40 patients who underwent emergency surgery for CES. There were 22 women and 18 men with a mean age of 38.6 years. 92 patients underwent elective lumbar discectomy. There were 45 men and 47 women with a mean age of 44 years. Patient undergoing emergency discectomy for CES were significantly heavier (p=0.001) and had a significantly higher BMI (p< 0.0005) compared to the elective surgery cohort. The mean difference in weight and BMI were 11.2 kg (95% confidence interval: 3.8–18.7) and 4.6kg/m2 (95% confidence interval: 2.4–6.9) respectively. The CES-group was also slightly younger (mean difference 5.4 years 95% CI: 1.7–9.8 p=0.01). There was no statistically significant difference between the heights of the two groups or the gender ratio. Multivariate binary logistic regression showed increasing weight to be associated with the increasing odds of CES (P< 0.0005). In contrast increasing height was correlated with a reducing likelihood of CES (P< 0.01). Increasing BMI was associated with increased odds of CES (p< 0.0005). Conclusion. This is the first study to relate anthropometric features to CES. Our study observed that increasing BMI is linked with the increased odds of CES syndrome as was increasing weight and decreasing height

Background. Cauda Equina Syndrome (CES) needs to be diagnosed and managed promptly to ensure the best outcome for patients. Our current spinal service has been centralised, with referrals currently delivered via an online system. This means that patients aren't seen by spinal specialists until confirmed radiological diagnosis. To ensure patient safety, we must make sure that our CES pathway is as robust as possible. Methods & Results. A Google Forms questionnaire was emailed to various health professionals involved in the CES patient journey throughout the Lancashire & South Cumbria region. Participants were asked to identify problems with our current pathway and to provide possible solutions for improvement. 64 responses were received from 5 different departments throughout 6 NHS employers: 21 (33%) consultants, 6 (9%) middle grade doctors, 31 physiotherapists (48%), 3 (5%) GPs and 3 (5%) others. Many common themes were identified: the need to improve CES education to both referrers and patients (22% responses), addressing the issue of scan availability (39% responses), the need for a clearer pathway for GPs (26% responses) among others. Participants were asked to rate their confidence in the management of both suspected (mean=7.6 +/−2.3) and diagnosed CES (mean=8.0 +/− 2.0). Discussion. These results have made it evident that there is a need for improvement to our current CES pathway at all levels. Our current system is overloaded with poor referrals that backlog the MRI scanner, leading to delays. Providing training for referrers in the first instance may improve things, however a more thorough overhaul of the pathway is required. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Aims. Cauda equina syndrome (CES) is a rare condition which requires urgent treatment to reduce the risk of long term neurological morbidity. Most authors recommend surgical decompression within 24–48 hours of the onset of symptoms, which may not be possible if there are delays in referral to hospital, performance of diagnostic imaging or poor access to a spine surgeon. We present a snap shot of referrals of patients with suspected cauda equina syndrome to the Orthopaedic department in a district general hospital including the diagnoses, management and outcome. Methods. A retrospective review of 20 consecutive patients (mean age 49, 11 males, 9 females) referred via Primary Care to the orthopaedic on call team between April and December 2010 was carried out. Data were recorded including the clinical symptoms and signs on admission, time taken to undergo MRI, diagnosis and treatment. Results. 18/20 patients had red flag symptoms. Two patients with convincing neurological evidence of CES were transferred to the local neurosurgical unit for urgent assessment and surgical intervention. 12 patients required urgent inpatient MRI scans; mean time to MRI for these patients was 22 hours from the initial Orthopaedic assessment. Of these, none showed cauda equina and 3 were offered elective surgery for spinal nerve root compression. 14 out of 20 patients presented outside normal working hours when immediate access to MRI was unavailable. Conclusions. The majority of patients in this study had red flag symptoms, although few actually had CES. Usually patients present in the evening when access to MRI is unavailable, potentially delaying the diagnosis. Such information may be useful to radiology departments to help plan out of hours services or help district hospital Orthopaedic departments develop protocols with nearby neurosurgical units for rapid patient transfer when CES is suspected

Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures. We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable. We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ

Introduction. The authors recognised that patients presenting to the Orthopaedic Spinal Rapid Access Service with symptoms and or signs of cauda equina syndrome may not have the diagnosis confirmed radiologically. Altered sensation in the ‘saddle area’, bilateral sciatica, urinary incontinence or retention, altered bowel habit, and sexual dysfunction are well recognised symptoms of cauda equina syndrome. Recognised side-effects of neuropathic medications commonly prescribed for radicular pain include: altered sensation, urinary incontinence or retention, and sexual dysfunction. We have undertaken a retrospective cohort analysis in order to identify the relationship between prescribed medications and presenting symptoms and signs. Method. 151 patients were referred to the service within a 6 month period. Case notes of 34 patients presenting with symptoms and or objective signs of CES in absence of positive radiological findings were reviewed. Data collected included the patient's age, sex, prescribed medications and presenting symptoms. Results. Of these 34, 9(26%) presented with altered bladder function and ‘saddle area’ sensation and 25(74%) with isolated bladder symptoms. Mean age was 47 in both female and males, 26 females and 8 males. 16(47%) were taking neuropathic medications, 7(22%) anti-depressants and 9(28%) anti-convulsant medications. Conclusion. 16(47%) of patients presenting with CES in the absence of radiological evidence were prescribed neuropathic medications with known side effects that may contribute to their symptoms. Therefore clinicians should take due consideration of prescribed medications as a possible cause of CES signs and symptoms. Further work is required to analyse data from a larger patient population in order to identify if particular medications carry a higher risk. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Objective: A clear definition of cauda equina syndrome (CES) following herniated discs was not available from the literature. Some define CES as a total paralysis of the pelvic viscera. 1. while others consider any dysfunction as sufficient evidence of CES. 2. An extensive search of the literature also demonstrated a lack of a disease specific outcome measure for CES. We aimed to classify CES in the above spectrum and validate a new outcome score for CES. Design and subjects: We present a retrospective study of 38 patients with a minimum of one-year follow up who presented with an acute cauda equina syndrome. We categorized the patients as complete or incomplete and further sub-classified them as acute or chronic. A total paralysis of the pelvic viscera was considered as complete. Presence of only dysfunction of the pelvic viscera was considered as incomplete. If the presenting episode plateaued within 24 hours or less of onset it was classified as acute and if it plateaued later than 24 hours it was considered as chronic. Outcome measures: The new 17-item disease specific questionnaire was compared with the Oswestry Disability Index, SF36 and Urodynamic studies. Results and conclusion: Of the patients studied, 44.7% were complete with acute onset, 21.1% were complete with chronic onset, 10.5% were incomplete with acute onset and 23.7% were incomplete with chronic onset. Outcome score matched the spectrum of our suggested classification

Purposes of the study and background. A Qualitative study exploring patient's experience of Cauda Equina Syndrome (CES) was carried out. The aim of this study was to identify how Cauda Equina Syndrome symptoms may be more effectively identified by patients and their clinician. Patient's symptoms and experiences of their condition were explored, including issues associated with bladder, bowel and sexual function. A summary of the methods used and the results. Via in-depth questions, participants were enabled to share their stories within a confidential setting. Narrative analysis of the patient's story allowed symptom progression and recognition to be explored and language used by participants themselves to describe symptoms identified. Seven themes emerged from the study. The findings were used to develop clinical tools to assist in the consultation process of potential CES patients. Finally the tools were validated by CES patients and clinicians prior to use within a clinical setting. Conclusion. The findings of this research have been utilised, working with patients as partners, to establish clear, sensitive and understandable language to use during clinical questioning of potential CES patients. This patient choice of language for sensitive questions has been replicated on a clinical cue card to use during the consultation and on a credit card sized leaflet to give to patients. Working with patients, clear methods of communication have been developed surrounding potentially embarrassing but critical symptoms in order to assist ‘bringing the individual patient and the surgical team together at the earliest practical opportunity’. No conflicts of interest. Source of funding; Physiotherapy Research Foundation (Part of the CSP Charitable Trust registered charity 279882)

In this study we aim to establish which symptoms and signs are able to reliably predict the presence or absence of cauda equina syndrome. Prospective collection of data was carried out over 10 months on all patients referred with suspected cauda equina syndrome(CES) to a single spinal unit. 28 patients were referred. MRI was normal in 4 (14%) patients. 4 (14%) had disc prolapse causing CES and 3 (11%) had spinal metastatic disease. All patients with CES presented with low back pain, unilateral sciatica, urinary dysfunction (painless retention 2, incontinence 2), altered perianal sensation and abnormal anal tone. 1 described constipation. Of patients without CES or malignancy 21 (100%) complained of low back pain, 19 (90%) sciatica (15 unilateral, 4 bilateral), 12 urinary dysfunction (incontinence 5, reduced sensation 3, painless retention 2, urgency 1, terminal dribbling 1) and 5 described altered bowel habit. 7 (33%) exhibited altered perianal sensation and 1 (5%) abnormal anal tone. The patients with spinal metastases all described back pain but no sciatica. 2 had urinary retention and constipation with 1 having abnormal perianal sensation and anal tone. This study suggests abnormal anal tone (sensitivity 1.0, specificity 0.95) and altered perianal sensation (sensitivity 1.0, specificity 0.67) are the most reliable predictors of CES. Thorough clinical examination is essential. Back pain with bladder and/or bowel dysfunction without sciatica should raise the suspicion of malignancy

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

Purpose and background. Cauda equina syndrome (CES) leads to nerve compression in the lumbar spine, and requires immediate treatment to prevent permanent neurological dysfunction, including urinary/anorectal incontinence. The consequences for the patient are significant as, in the decade to 2018, CES has cost the NHS £186,134,049. No study has reported patients’ experiences of being managed with suspected CES in an emergency department (ED), and this study explores patients’ experiences and how the NHS can optimise care for patients experiencing this condition. Methods and Results. In this qualitative secondary analysis, 14 participants (aged 23–63 years) with suspected CES were purposively sampled from 4 EDs in England. Online, semi-structed interviews were undertaken (in 2021, during the pandemic), and were audio-recorded and transcribed verbatim. Data were managed using a Framework approach and analysed thematically. Three themes were identified: quality of care; environmental factors; and expectations. The quality of care included managing uncertainty, the importance of communication, appropriate assessment and follow-up care. Environmental factors, including the chairs, waiting times and the busy nature of the ED, negatively impacted patients’ experiences. Furthermore, an expectation gap was identified, as most individuals came to the ED expecting to receive a scan, an accurate diagnosis and a cure. Despite frustrations, patients expressed gratitude towards the ED staff. Conclusion. This study highlights the importance of empathically acknowledging the patient's pain and providing comprehensive assessments and management plans for people attending ED with suspected CES. Optimising the ED environment to minimise patients’ pain and distress while waiting to access care is paramount and overdue. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Introduction: Recent articles in the MPS Casebook (Cauda equina syndrome, Gardner and Morley) and BMJ (Cauda Equina Syndrome, Lavy) highlighted the potential dangers of Cauda equina syndrome (CES). CES has the highest rates of litigation due to the risk of symptoms not resolving and having a devastating impact on patients. This study aimed to assess clinician knowledge of the urinary symptoms of CES and the timeframe in which treatment should be offered. Method: A 4 part questionnaire was constructed. The first part established the status and type of health care professional. The second part assesses how many musculoskel-etal patients are seen in an average week. In the third part the participant is asked to rank 15 urinary symptoms; with 1 being the least alarming and 15 being the most alarming. 7 of the symptoms were not related to CES and so should have been ranked in the bottom seven. Lastly, to highlight an issue raise in the BMJ article; the participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES, with the options being within 24 hours; 24–48 hours; and 48 hours to 2 weeks. The questionnaire was distributed to Health Care Professionals in Southport and Ormskirk Hospital. Results: The questionnaire was completed by 23 participants (12 Doctors and 11 Physiotherapists). 90.91% of Physiotherapists and 10 Doctors (83.3%) managed to complete the questionnaire as specified. An average of 24 patients was seen by each professional (25 patients doctors; 31 patients Physiotherapist). The 7 false CES urinary symptoms were ranked in the bottom 7 in 76.40% of questionnaires (77.92% in Doctors; 81.82% in Physiotherapists). True CES urinary symptoms were ranked in the bottom 7 in 59.63% of cases (66.23% Doctors; 58.44% Physiotherapists). Finally 91.30% of those asked thought Complete CES should be treated within 24 hours (83.33% Doctors; 100% Physiotherapist); 56.52% thought Incomplete CES should be treated within 24 hours (66.67% Doctors; 45.45% Physiotherapists); 30.43% within 24 to 48 hours (8.33% Doctors; 54.55% Physiotherapists) and lastly 13.04% thought Incomplete CES should be treated within 2 weeks (25% Doctors and 0% of Physiotherapists). Conclusion: The results show that there is a gap in knowledge of all professional with regards to CES urinary symptoms and the optimal timing of treatment. The results showed that Physiotherapists are more likely to recognise True CES than doctors. False symptoms were ranked lower by Physiotherapists than Medical Professionals. These results demonstrate that physiotherapists are better than Doctors at identifying urinary symptoms in CES. Finally the majority of those asked would treat Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical personnel in the symptoms of Cauda Equina Syndrome and also the timing of treatment